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Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: <br /> Labor a uman Relations INSPECTION REPORT r <br /> Safety andnd Buildings Division <br /> (ATTACH TO PERMIT) Sanitary PermitNo <br /> GENERAL INFORMATION Mol <br /> P it HoIdei s Na ❑ City ❑ Village ATown of: State Plan ID No <br /> CST BMElev.: Insp.B ev.: BM Description: Parcel Tax No <br /> b6— toy _ 30 6 fir, CAZ" , ) - a -- <br /> TANK INFORMATION ELEVATION DATA / <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FSrLE <br /> Septic S S Benchmark P.M ��,3y DosingAeration - Bldg.SewerHolding St/Ht Inlet �(p , 2f <br /> TANK SETBACK INFORMATION St/Ht Outlet S,() C •3 <br /> TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet <br /> Air Intake <br /> Septic NA Dt Bottom s 3 cls U L <br /> Dosing NA Header/Man. <br /> Aeration NA Dist, Pipe 5. 6,99 <br /> Holding Bot. System (0 8 C16, <br /> PUMP/SIPHON INFORMATION Final Grade <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDH Lift Friction System TDH Ft <br /> Head <br /> Forcemain Length Dia. Dist.To well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width ( Length t No.Of Trenches PIT No Of Pits Inside Dia. Liquid Depth <br /> DIMENSIONS (- d / DIMENSIONS <br /> SYSTEM TO P/L ' BLDG I WELL LAKE/STREAM LEACHING Manufacturer: <br /> SETBACK CHAMBER <br /> INFORMATION Type O Cru Soy S-o r Sa I �sU / OR UNIT Model Number: <br /> System: 1, <br /> DISTRIBUTION SYSTEM <br /> Header/Manifold Distribution Pipe( L, r x Hole Size x Hole Spacing Vent To, <br /> iAAiiyr Intake <br /> Length(/� Dia. Length ,9- Dia. 1 / Spacing —6— /C.� <br /> SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only <br /> Depth Over Depth Over xx Depth Of xx Seeded/Sodded xx Mulched <br /> Bed/Trench Center Bed/Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No <br /> COMMENTS: (Include code discrepancies, persons present,etc.) <br /> Plan revision requiredE] Yes 1171 No <br /> Use other side for additional infor Ion. �( <br /> SBD-6710(R 05/91) Date Inspect, sSignature Cert.No. <br />